Fillable STATE OF GEORGIA Georgia Department of Community Affairs (Georgia.gov)

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STATE OF GEORGIA Georgia Department of Community Affairs (Georgia.gov)

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Updated June 2013
STATE OF GEORGIA
Georgia Department of Community Affairs (DCA)
REQUEST FOR REASONABLE ACCOMMODATION
DCA personnel want to make our services and facilities accessible to all. Your requests
and recommendations are welcome. If you know in advance that you will require
accommodation services, please complete this Request for Reasonable Accommodation
Form and return to a Division Coordinator (see attached list with email and telephone
numbers) or e mail it to
fairhousing@dca.ga.gov.
If you need assistance completing this form, contact the Division Coordinator.
Note: Some types of reasonable accommodations (e.g., readers, sign language
interpreters, brailled/alternative formatted materials) require advance notice. Requests
for reasonable accommodations will be evaluated on a case by case basis. There
must exist a nexus or connection between your condition and the
accommodation(s) that you are requesting.
You may be required to complete a Documentation in Support of Request Form and
Limited Medical Release for DCA to properly evaluate your reasonable accommodation
request(s). This information, if required, will remain confidential and will only be used
to evaluate your accommodation request(s).
Name: _____________________________________________________
Address: ____________________________________________________
____________________________________________________
____________________________________________________
Telephone No.: _______________________________________________
E-mail: _____________________________________________________
Updated June 2013
I am participating in the following DCA service/program/activity as a (check all that
apply):
Program Name
Other (please specify):
______________________________________________________________________
I am requesting accommodation because (please check one or more of the following)
I am requesting accommodation that will allow me to participate in a program or
activity offered by DCA.
I am requesting an exception to the following rule, policy or procedure. Please
specify the reasons necessary for the exception and the exception requested.
__________________________________________________________________
__________________________________________________________________
Auxiliary Aid or Service (for example, sign language interpreter, the way that
DCA communicates with you).
Please specify:
______________________________________________________________________
Describe the impairment that necessitates the accommodation(s) (specify):
______________________________________________________________________
______________________________________________________________________
Describe the accommodation(s) you are requesting and explain how the requested
accommodation(s) would be effective.
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
Updated June 2013
Are you aware of alternative methods that might effectively accommodate your
impairment?
Yes No If yes, specify:
__________________________________
__________________________________
List all dates/times the accommodation(s) are needed (specify):
__________________________________
__________________________________
Please identify any potential resources or other suggestions for DCA to consider in
responding to your accommodation requests.
__________________________________
I request that all information pertaining to my accommodation request:
Be kept confidential Not be kept confidential
Date: _____________________________
_________________________________
(Print Name) (Signature)
Updated June 2013
Review and Action
Reasonable Accommodation Request Form received from applicant on _______ (Date).
If necessary, Request for Additional Information requested on _______ (Date).
If necessary, Request for Additional Information completed and returned on _______
(Date).
Requested Accommodation granted on _______ (Date).
Requested Accommodation denied on ________ (Date) because:
__________________________________
__________________________________
Other action taken (explain) on _______ (Date).
__________________________________
__________________________________
Notification to applicant concerning action taken on _______ (Date).
______________________ _________________________________
(Date) (Signature of DCA Official)
Updated June 2013
STATE OF GEORGIA
Georgia Department of Community Affairs (DCA)
REASONABLE ACCOMMODATION REQUEST
Documentation in Support of Request: Health Care Professional Information
Please answer the following questions regarding ______________________’s condition
Individual
as it relates to his/her ability to participate in _______________________________ and
Program
possible accommodations. _______________________ signed Limited Medical
Individual
Release is also attached.
This information is requested so that DCA can properly evaluate this individual’s request
for an accommodation to participate in _______________________________
Program
Does the individual have a mental or physical impairment that substantially limits a major
life activity? If so, describe the impairment and its impact on this individual’s major life
activities. (Major life activities include, but are not limited to, walking, seeing, hearing,
speaking, breathing, learning, performing manual tasks, caring for oneself.)
Does the impairment affect the individual’s ability to participate in the essential eligibility
requirements for the program? If so, please describe the impact on the person’s ability
to perform specific functions.
__________________________________
__________________________________
__________________________________
__________________________________
Updated June 2013
Is the need for accommodation likely to be temporary or permanent? If temporary, how
long do you estimate the need for accommodation will exist?
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
_______________________________ _____________________________
Health Care Professional name Professional license or specialty
(please print)
_______________________________ _____________________________
Signature Date
Updated June 2013
STATE OF GEORGIA
Georgia Department of Community Affairs (DCA)
REASONABLE ACCOMMODATION REQUEST
Documentation in Support of Request: Release
I hereby authorize ___________________________________ to provide the medical
information requested by DCA. The information will solely be used to evaluate my
request for reasonable accommodation under the Americans with Disabilities Act and
Section 504 of the Rehabilitation Act of 1973.
________________________________ _________________________
Name (Please print) Telephone/E-mail
________________________________ _________________________
Signature Date
[Attach cover letter from DCA explaining reason for requesting information.]
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Completed 28 September 2021

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